Provider Demographics
NPI:1285603787
Name:MANZ, MARY S (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:S
Last Name:MANZ
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N793 ELM STREET
Mailing Address - Street 2:PO BOX 2
Mailing Address - City:DALTON
Mailing Address - State:WI
Mailing Address - Zip Code:53926-0002
Mailing Address - Country:US
Mailing Address - Phone:920-394-3791
Mailing Address - Fax:
Practice Address - Street 1:N 793 ELM STREET
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:WI
Practice Address - Zip Code:53926-0002
Practice Address - Country:US
Practice Address - Phone:920-394-3791
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49793-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39939700Medicaid